---
title: 'Clinical Presentation'
type: 'lesson'
url: 'https://doc.social/courses/surgical-treatment-of-degenerative-spondylolisthesis/clinical-presentation'
course: 'Surgical Treatment of Degenerative Spondylolisthesis'
course_url: 'https://doc.social/courses/surgical-treatment-of-degenerative-spondylolisthesis'
position: '3 of 4'
author: 'Dr. Paul Houle'
transcript: 'yes'
---

# Clinical Presentation

## Summary

_This lesson is a recording without a written summary._

## Transcript

1,862 words · 10 min · 3 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: Great, so, um, we've got about, uh, 12 minutes left, um, and I wanna send a little shout out here to, uh, uh, Doctor Brzezinski who joined us from Dubai. It's 3 a.m. there, so he gets, he gets the prize for, for showing up at 3 a.m. to listen to us talk, but a case I'd like to present is the case of a 77-year-old woman.
[0:26] Speaker 1: Um, elderly, uh, you know, not too elderly, but elderly enough, but had a history of pulmonary embolus in the past and has severe coronary vascular disease, and her problem is just classic claudication. She can't walk the length of her driveway, uh, and that's about as much exercise as she gets, and that's something that she really wants to do. Obviously her, her Pain gets better when she bends forward at the waist and when she sits down, and she has a little bit more left leg Pain than right leg Pain.
[0:53] Speaker 1: So, um.
[0:58] Speaker 1: Here's a, here's her picture. Her, she had a CT scan, uh, actually of her abdomen, and this was the, the Spine views, and you can see she's got, uh, pneumocephalus within the disc spaces. She's got scoliosis. She's got a, a, a coronal imbalance, um, and a degenerative listhesis, and you see a partial cal calcification at L4-5.
[1:20] Speaker 1: And so you see this and you're like, well, OK, well what, what's, what are my treatment options for her? I, I can certainly go in there and, and do a fusion, but, you know, where do you, where do you stop? What level do you stop at? Um, her, her symptoms are neurogenic claudication, period. She doesn't have a tremendous amount of back Pain. She and all she wants to do is to be able to walk and get her mail.
[1:43] Speaker 1: And here's her MRI. She has significant central stenosis from ligamentous hypertrophy. She has fairly significant lateral recess stenosis. And, um, as we go out and look at her foramen, um, her left and right foramen are tight, but they're not terribly tight.
[2:01] Speaker 1: But if we go back and look at her CAT scan, I, I think she's probably collapsed as much as she's gonna collapse, and so her distal neural foramen are probably, uh, as, as narrow as they're gonna get, and so then the question becomes is this someone that we do a fusion on? Is this someone that we do a laminectomy on or, or something else? And my, my preferred Approach in this, uh, elderly population is just a simple minimally invasive laminectomy.
[2:29] Speaker 1: And I don't have post-op films because I don't get them, but, um, I just did a simple, uh, tubular bilateral, uh, decompression to a unilateral incision. So over the top sublaminar decompression, um, I know in your case, Ray, that you showed your operative times, but this operative time was, you know, less than 40 minutes. She's in the hospital for basically a total of 4 hours, went home and had complete resolution of her symptoms, and she's almost a year out now, uh.
[2:58] Speaker 1: And I looked at her medical record from her Primary care doctor, and she has no mention of her back or claudication symptoms.
[3:06] Speaker 1: So I think here we are raising the question, you know, what is the optimal treatment? Well, just like you said, there's more than one optimal treatment and then we have to, you know, tailor it to the patient's wishes as well. Um,
[3:21] Speaker 2: so I'll, I'll come in briefly in that, um,
[3:24] Speaker 2: You know, certainly, I, I, I, I would, I would love to see the standing films, but I can see how that would uh potentially uh send us down the wrong path. It's so common that we look at films and get so focused on the deformity, uh, and we don't pay attention to, to the patient. And um it becomes a very slippery slope when you start to see somebody with a bit of Rotator subluxation, a bit of loss sloidosis, and
[3:47] Speaker 2: Uh, this could easily be a case that, uh, you could talk your way into a T10S1 on, uh, versus a single level two-based 45 minute or 40-minute decompression. So, um, I, I, I think it's, it's, it's easy to go down, go down the wrong path for a patient who in this case, uh, really, really had neurogenic claudication.
[4:06] Speaker 1: Now I would say that where I think a simple decompression alone has the potential to fail is when there is severe distal foraminal stenosis because you can go ahead and decompress the lateral recess and you can decompress the central canal and they're still gonna have uh radicular symptoms because the uh nerve foramen are not decompressed and so that's where I think you introduce inner body, uh, and, and get a secondary decompression of the nerve foramen.
[4:35] Speaker 1: So that was one of the questions, uh, that was asked about, you know, uh, for symptomatic foraminal stenosis due to a degenerative spondi that was a question that was asked and that's my, that's my feeling. I, I do think that while I tend to do more decompressions than I do fusions, I do recognize that distal foraminal stenosis is a very significant problem and if we ignore it, uh, patients are gonna have bad outcomes.
[5:01] Speaker 3: You know, I'd also expect to see on that patient, if you did flexion extension X-rays, not a lot of motion because despite the fact that there's, uh, you know, vacuum phenomenon on the disc, it looks like the disc has gone on to autofuse. So, she went through the instability phase of degeneration, she's progressed to the stabilization phase. She's got severe stenosis. I think you can feel pretty good about decompressing this patient if there's no motion.
[5:23] Speaker 3: Um, and I don't, I don't suspect there would be. Um, you know, this is something that I would do endoscopically with the patient under conscious sedation. So, we don't even put them under general anesthesia anymore for this. So, from that point of view, even if you did the decompression and you end up having to do the fusion, it's still almost like a virgin Surgery if you're doing it through a, a, a TLLF Approach because the plane that you're working through hasn't been violated. If anything, it just makes your facetectomy a little bit easier.
[5:50] Speaker 3: So, not that I, not that I wanna do multiple surgeries on a 77-year-old. Don't, don't misconstrue that. But, you know, for a younger patient, you know, 5 years ago, I would have been much more dogmatic about wanting to fuse that patient. Having the ability to do this in a less, less invasive Approach.
[6:09] Speaker 3: Um, and, and, and not even having to do it under general anesthesia, I have a tendency to do the smaller procedure and see how it goes cause I don't feel like I've compromised them much if I have to do the larger procedure.
[6:22] Speaker 1: So in the last 5 minutes, one of the questions that we're getting, uh, is what do you feel is the next big trend in innerbody spacers in the coming years and where is there the most room for improvement that has not been tapped into,
[6:37] Speaker 3: right?
[6:39] Speaker 3: Well, again, I think it's uh being able to insert a spacer through a small portal and have a lift size footprint. So, you know,
[6:48] Speaker 3: The, the next realm of posterior antibodies is gonna be endoscopic. That's, that's the least invasive way you can possibly do it. You're basically operating through a straw of the size of a #2 pencil. And when you can deploy something through a, say, an 8 millimeter cannula,
[7:03] Speaker 3: And uh have a nice footprint and prevent subsidence, but still recreate lardosis, you know, I think that's gonna be a game changer because whether you do that through a TLIF Approach, a cliff Approach, heck, if even if you're doing an anterior to the POAS or through the POAS, if you can make a smaller hole in the POAS and still have a bigger footprint, why wouldn't that be better?
[7:24] Speaker 2: I agree. Well, I'll add to that. I think I'm most optimistic, uh, similarly about, uh, being able to get a better footprint, less subsidence, uh, being able to really get a, a meaningfully structural, uh, graft into the innerbody space. Uh, I'm also very optimistic about surfaces, and new surface technologies, and I think that that combining the two is, is, is, uh, where I see the most opportunity for, for change.
[7:52] Speaker 1: All right, well, I know Dr. Burvin that you have to, have to go. So I'd like to give the opportunity to say a few closing remarks, if you have any.
[8:08] Speaker 2: Well, thanks for participated. I think one of the messages that Ray Ray and I converged on here is uh
[8:15] Speaker 2: We probably do typically have a bit of a different Approach is recognizing the right Approach for the right patient and recognizing, I think there is a role for decompression only. I think that some of the traditional literature from from Hurkowitz and others has got to be revisited in the setting of endoscopic decompressive techniques and the setting of more minimally invasive decompressive techniques.
[8:37] Speaker 2: I also think that we showed that there's an important role for, for doing real reconstructions for, for uh uh creating segmental loosis and for paying attention to that in our patient evaluations and, and really recognizing the, the full spectrum of the continuum of options and, and, uh, and being able to offer the right solution to the right patient is, is gonna be ultimately the most appropriate option.
[9:00] Speaker 1: Excellent. uh, Doctor Gardai, I know you do a lot of, uh, minimally invasive and endoscopic Surgery. Um, what do you see, uh, happening in the future for you?
[9:13] Speaker 3: Well, I see, uh, the endoscope becoming a larger and larger part of my practice, because again,
[9:18] Speaker 3: You can achieve the fundamental basics of the of the procedure. So you can do the decompression, you can do the stabilization. You can't compromise on the fundamental goals. That's one thing I want to be clear on. Some people think minimally invasive is minimally effective, so,
[9:31] Speaker 3: You know, if, if you do a poor Surgery, whether it's done minimally invasively or open, it's still a poor Surgery. Uh, Doctor Burvin showed pictures of, of the postolateral fusion, two levels with instrumentation that induce somebody into, into kyphosis in a flatback. That person wasn't better off having a, a larger Surgery.
[9:48] Speaker 3: So, you know, the fundamentals are still the fundamentals and have to be achieved. But if you can achieve them less invasively, with less disruption of the soft tissues, of the dynamic stabilizers, and the structural integrity of the Spine, um, I think you're gonna be able to
[10:04] Speaker 3: Get better results with less Pain, less narcotic use, which is a major issue in the United States today, and uh faster recovery. So, you know, in my hands, the endoscope is going to become a bigger and bigger part, and I'm hoping to convert basically all my practice to endoscopic.
[10:19] Speaker 1: Excellent.

## In this course

- [Previous: Degenerative Spondylolisthesis Case Presentations](https://doc.social/llms/courses/surgical-treatment-of-degenerative-spondylolisthesis/degenerative-spondylolisthesis-case-presentations.md)
- [Next: Closing](https://doc.social/llms/courses/surgical-treatment-of-degenerative-spondylolisthesis/closing.md)
- [All lessons: Surgical Treatment of Degenerative Spondylolisthesis](https://doc.social/llms/courses/surgical-treatment-of-degenerative-spondylolisthesis.md)